HEALTH CARE DIRECTIVE (LIVING WILL) 

I, [FULL NAME] (“Principal”), want everyone who cares for me to know what health care I want when I cannot let others know what I want.

SECTION 1:

I want my doctor to try treatments that may get me back to an acceptable quality of life. However, if my quality of life becomes unacceptable to me and my condition will not improve (is irreversible), I direct that all treatments that extend my life be withdrawn.

A quality of life that is unacceptable to me means (check all that apply):

☐ – Unconscious (chronic coma or persistent vegetative state)
☐ – Unable to communicate my needs
☐ – Unable to recognize family or friends
☐ – Total or near total dependence on others for care
☐ – Other: [OTHER]

Check only one:

☐ – Even if I have the quality of life described above, I still wish to be treated with food and water by tube or intravenously (IV).
☐ – If I have the quality of life described above, I DO NOT wish to be treated with food and water by tube or intravenously (IV).

SECTION 2: (You may leave this section blank)

Some people do not want certain treatments under any circumstance, even if they might recover. Check the treatments below that you do not want under any circumstances:

☐ – Cardiopulmonary Resuscitation (CPR)
☐ – Ventilation (breathing machine)
☐ – Feeding tube
☐ – Dialysis
☐ – Other: [OTHER]

SECTION 3:

When I am near death, it is important to me that: [LIST PREFERENCES]

(This section may include preferences such as hospice care, place of death, funeral arrangements, cremation, or burial selections)

As the principal, I fully understand my rights regarding this living will and the availability of health care treatment options. I have made my selections above of my free will and without coercion from any 3^rd party.

Principal’s Signature: ___________________________ Date: ____________

Print Name: ___________________________